Post-exposure Prophylaxis Awareness, Knowledge, Access and Use Among Three Populations in New York City, 2016-17

A behavioral economics approach to enhancing HIV preexposure and postexposure prophylaxis implementation

PURPOSE OF REVIEW

The 'PrEP cliff' phenomenon poses a critical challenge in global HIV PrEP implementation, marked by significant dropouts across the entire PrEP care continuum. This article reviews new strategies to address 'PrEP cliff'.

RECENT FINDINGS

Canadian clinicians have developed a service delivery model that offers presumptive PEP to patients in need and transits eligible PEP users to PrEP. Early findings are promising. This service model not only establishes a safety net for those who were not protected by PrEP, but it also leverages the immediate salience and perceived benefits of PEP as a natural nudge towards PrEP use. Aligning with Behavioral Economics, specifically the Salience Theory, this strategy holds potential in tackling PrEP implementation challenges.

SUMMARY

A natural pathway between PEP and PrEP has been widely observed. The Canadian service model exemplifies an innovative strategy that leverages this organic pathway and enhances the utility of both PEP and PrEP services. We offer theoretical insights into the reasons behind these PEP-PrEP transitions and evolve the Canadian model into a cohesive framework for implementation.

Longitudinal predictors of post-exposure prophylaxis awareness among latino sexual minority men in South Florida

Biomedical tools for HIV prevention such as post-exposure prophylaxis (PEP) continue to be underutilized by subgroups experiencing significant HIV inequities. Specifically, factors associated with both PEP awareness and uptake both cross-sectionally and longitudinally are under-researched, despite PEP being a part of the United States' Plan for Ending the HIV Epidemic. The current study examined longitudinal predictors of PEP awareness among Latino sexual minority men (LSMM) living in South Florida. This current study (N = 290) employed hierarchal linear modeling across three timepoints (baseline, 4-months, 8-months) to assess within-person and between-person effects over time for several psychosocial and structural factors. Most participants (67.5%) reported little to no awareness of PEP at baseline with general PEP awareness growing slightly across the study (60.5% reporting little to no awareness of PEP at 8 months). Results of the final conditional model suggest significant within-person effects of PrEP knowledge (p = 0.02) and PrEP self-efficacy (p < 0.001), as well as a significant positive between-person effect of PrEP knowledge (p < 0.01) on PEP awareness. Between-person HIV knowledge was also a significant predictor in this model (p = 0.01). This longitudinal analysis of LSMM's PEP awareness indicates that more must be done to increase PEP awareness among this subgroup. Future studies should explore how to build on existing interventions focused on HIV and PrEP knowledge and PrEP self-efficacy to incorporate information about PEP to increase the reach of this effective biomedical HIV prevention tool.

Navigating Barriers and Opportunities: Perceptions of the Non-Occupational Post-Exposure Prophylaxis Care Continuum Among Young Sexual Minority Men, Aged 17-24, in the United States

Human immunodeficiency virus (HIV) is a public health concern among young sexual minority men (YSMM), ages 17 to 24, in the United States. Biomedical prevention methods, such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP), can help reduce the risk of HIV transmission among this population. However, there is limited awareness and use of nPEP by YSMM. This study aims to explore the perceptions of YSMM regarding the nPEP care continuum, which consists of three areas of focus: awareness, uptake, and linkage to other HIV prevention services. This study draws on synchronous online focus groups with a sample of 41 YSMM in the United States. Transcripts from the focus groups were analyzed using reflexive thematic analysis. Participants reported limited nPEP awareness and prior use, a process of personal appraisal of nPEP need based on HIV risk and costs, and a preference for PrEP over PEP for long-term HIV prevention. Interventions should be tailored to increase awareness of nPEP among YSMM and reduce addressable barriers to nPEP use for YSMM, including cost and confidentiality concerns, in situations where nPEP is warranted. Finally, more research is needed on how nPEP use can act as a bridge to PrEP initiation for this population.

Awareness and uptake of non-occupational post-exposure prophylaxis (nPEP) among gay, bisexual and other men who have sex with men in China: a cross-sectional study

Non-occupational post-exposure prophylaxis (nPEP) is recommended to reduce the likelihood of HIV infection after potential exposure. However, little is known about this practice among Chinese gay, bisexual and other men who have sex with men (GBM). GBM were enrolled from both centers for disease prevention and control (CDCs) and community health centers in six cities in China. Multivariable logistics regression was used to assess factors associated with awareness of and willingness to use nPEP. A total of 516 eligible GBM were included, 67.2% of whom were aware of nPEP, 76.0% were willing to use nPEP, and 2.3% had ever used nPEP. GBM who had college or higher education, had disclosed sexual orientation, had increased number of male sex partners in the last 6 months, and had ever tested for HIV were more likely to be aware of nPEP. Willingness to use nPEP was significantly associated with college or higher education, STI history, gay app use, and awareness of nPEP prior to study. Uptake of nPEP is still low among MSM in China. Efforts are needed to improve awareness of and access to nPEP among GBM, especially those at higher risk of HIV infection.

Trends of nonoccupational postexposure prophylaxis in the United States

OBJECTIVE

To describe national annual rates of nonoccupational postexposure prophylaxis (nPEP) in the United States.

DESIGN

Retrospective cohort study of commercially insured individuals in the Merative MarketScan Database from January 1, 2010 to December 31, 2019.

METHODS

Patients at least 13 years old prescribed nPEP per recommended Centers for Disease Control and Prevention guidelines were identified using pharmacy claims. Rates of use were described overall and stratified by sex, age group, and region. These rates were qualitatively compared to the diagnosis rates of human immunodeficiency virus (HIV) observed in the data. Joinpoint analysis identified inflection points of nPEP use.

RESULTS

Eleven thousand, three hundred and ninety-seven nPEP users were identified, with a mean age of 33.7 years. Most were males (64.6%) and lived in the south (33.2%) and northeast (32.4%). The rate of nPEP use increased 515%, from 1.42 nPEP users per 100 000 enrollees in 2010 to 8.71 nPEP users per 10 000 enrollees in 2019. The comparative nPEP use rates among subgroups largely mirrored their HIV diagnosis rates, that is, subgroups with a higher HIV rate had higher nPEP use. In the Joinpoint analysis significant growth was observed from 2012 to 2015 [estimated annual percentage change (EAPC): 45.8%; 95% confidence interval (CI): 29.4 - 64.3] followed by a more moderate increase from 2015 to 2019 (EAPC 16.0%; 95% CI: 12.6-19.6).

CONCLUSIONS

nPEP use increased from 2010 to 2019, but not equally across all risk groups. Further policy interventions should be developed to reduce barriers and ensure adequate access to this important HIV prevention tool.

Awareness and use of HIV pre-exposure prophylaxis and factors associated with awareness among MSM in Beijing, China

Human immunodeficiency virus (HIV) sexual transmission among men who have sex with men (MSM) has increased markedly in Beijing, China in the past decade. Pre-exposure prophylaxis (PrEP) is a highly efficacious biomedical prevention strategy that remarkably reduces HIV-transmission risk. This study examined PrEP awareness among MSM and the factors influencing it. From April to July 2021, respondent-driven sampling was used to conduct a cross-sectional survey among MSM in Beijing, China. Demographic, behavior, and awareness data regarding PrEP were collected. The factors influencing PrEP awareness were assessed using univariate and multivariable logistic regression. In total, 608 eligible responders were included in the study. Among the respondents, 27.9% had PrEP awareness, 3.3% had taken PrEP, and 57.9% expressed interest in receiving PrEP, if required. Greater odds of PrEP awareness were associated with higher education level (adjusted odds ratio [aOR] 3.525, 95% confidence interval [CI] 2.013-6.173, P < 0.0001), greater HIV-related knowledge (aOR 3.605, 95% CI 2.229-5.829, P < 0.0001), HIV testing (aOR 2.647, 95% CI 1.463-4.788, P = 0.0013), and sexually transmitted infections (aOR 2.064, 95% CI 1.189-3.584, P = 0.0101). Lower odds of PrEP awareness were associated with higher stigma score (aOR 0.729, 95% CI 0.591-0.897, P = 0.0029). The findings indicate sub-optimal awareness and low utilization of PrEP in Beijing and highlight PrEP inequities among MSM with stigma. Strengthening the training of peer educators in disseminating PrEP knowledge and reducing stigma are critical for improving PrEP awareness.

The Use of HIV Pre- and Postexposure Prophylaxis Among a Web-Based Sample of HIV-Negative and Unknown Status Cisgender and Transgender Sexual Minority Men: Cross-sectional Study

BACKGROUND

HIV disproportionately affects sexual minority men (SMM) in the United States.

OBJECTIVE

We sought to determine past HIV postexposure prophylaxis (PEP) use and current and prior pre-exposure prophylaxis (PrEP) use among a web-based sample of cisgender and transgender men who have sex with men.

METHODS

In 2019, HIV-negative and unknown status SMM (n=63,015) were recruited via geosocial networking apps, social media, and other web-based venues to participate in a brief eligibility screening survey. Individuals were asked about past PEP use and current and prior PrEP use. We examined associations of demographics, socioeconomic indicators, and recent club drug use with PEP and PrEP use, as well as the association between past PEP use and current and prior PrEP use using generalized linear models and multinomial logistic regression. Statistical significance was considered at P<.001, given the large sample size; 99.9% CIs are reported.

RESULTS

Prior PEP use was reported by 11.28% (7108/63,015) of the participants, with current or prior PrEP use reported by 21.95% (13,832/63,015) and 8.12% (5118/63,015), respectively. Nearly half (3268/7108, 46%) of the past PEP users were current PrEP users, and another 39.9% (2836/7108) of the participants who reported past PEP use also reported prior PrEP use. In multivariable analysis, past PEP use was associated with current (relative risk ratio [RRR] 23.53, 99.9% CI 14.03-39.46) and prior PrEP use (RRR 52.14, 99.9% CI 29.39-92.50). Compared with White men, Black men had higher prevalence of past PEP use and current PrEP use, Latino men had higher prevalence of PEP use but no significant difference in PrEP use, and those identifying as another race or ethnicity reported higher prevalence of past PEP use and lower current PrEP use. Past PEP use and current PrEP use were highest in the Northeast, with participants in the Midwest and South reporting significantly lower PEP and PrEP use. A significant interaction of Black race by past PEP use with current PrEP use was found (RRR 0.57, 99.9% CI 0.37-0.87), indicating that Black men who previously used PEP were less likely to report current PrEP use. Participants who reported recent club drug use were significantly more likely to report past PEP use and current or prior PrEP use than those without recent club drug use.

CONCLUSIONS

PrEP use continues to be the predominant HIV prevention strategy for SMM compared with PEP use. Higher rates of past PEP use and current PrEP use among Black SMM are noteworthy, given the disproportionate burden of HIV. Nonetheless, understanding why Black men who previously used PEP are less likely to report current PrEP use is an important avenue for future research.

HIV awareness and prevention strategies among transgender women in the Eastern and Southern United States: findings from the LITE Study

INTRODUCTION

Transgender women (TW) experience an increased risk of human immunodeficiency virus (HIV) acquisition. This study identified patterns of HIV awareness and prevention strategies used by TW who were not living with HIV.

METHODS

Data were drawn from a baseline survey of the LITE Study, a multi-site cohort of TW in Eastern and Southern United States (March 2018-August 2020). We conducted a latent class analysis to identify classes of HIV awareness and prevention strategies among TW who reported past 12-month sexual activity (N = 958) using 10 variables spanning HIV knowledge, receipt and use of HIV prevention strategies, and sexual practices. Due to differences across the cohort arms, classes were estimated separately for TW enrolled in site-based versus online study arms. We identified demographic characteristics, gender-affirming indicators and HIV vulnerabilities associated with class membership.

RESULTS

Four parallel classes emerged: class 1 "limited strategies-less sexually active" (15% and 9%, site-based and online, respectively), class 2 "limited strategies-insertive sex" (16%/36%), class 3 "limited strategies-receptive sex" (33%/37%) and class 4 "multiple strategies-insertive and receptive sex" (36%/18%). Across all classes, condomless sex, pre-exposure prophylaxis (PrEP)/post-exposure prophylaxis (PEP) prevention knowledge and awareness were high but reported PrEP/PEP use was low. Compared with class 1, membership in class 4 was associated with being a person of colour (site-based OR = 2.15, 95% CI = 1.15-4.00, online OR = 4.54, 95% CI = 1.09-18.81) increased odds of self-perceived medium-to-high HIV risk (site-based OR = 4.12, 95% CI = 2.17-7.80, online OR = 11.73, 95% CI = 2.98-46.13), sexually transmitted infections (STI) diagnosis (site-based OR = 6.69, 95% CI = 3.42-13.10, online OR = 8.46, 95% CI = 1.71-41.78), current sex work (site-based OR = 6.49, 95% CI = 2.61-16.11, online OR = 10.25, 95% CI = 1.16-90.60) and 2-4 sexual partners in the last 3 months (site-based OR = 2.61, 95% CI = 1.33-5.13). Class 3, compared with class 1, had increased odds of current sex work partners (site-based OR = 3.09, 95% CI = 1.19-8.07) and of having 2-4 sexual partners in the last 3 months (site-based OR = 3.69, 95% CI = 1.85-7.39).

CONCLUSIONS

TW have varied HIV awareness and prevention strategy utilization, with clear gaps in the uptake of prevention strategies. Algorithms derived from latent class membership may be used to tailor HIV prevention interventions for different subgroups and those reached through facility-based or digital methods.

Factors Associated with Post-Exposure Prophylaxis Awareness Among Latino Sexual Minority Men in South Florida

Despite their efficacy, biomedical HIV prevention tools such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) have been insufficiently scaled up and disseminated, especially among marginalized subgroups that face substantial HIV disparities. Given the minimal literature available on PEP among Latino sexual minority men (LSMM), this cross-sectional secondary analysis explored factors associated with PEP awareness among a group of LSMM living in South Florida, a US HIV epicenter. The parent study examined patterns of engagement in PrEP and behavioral health treatment services among LSMM (N = 290). The current secondary analysis (N = 243) identified factors associated with PEP awareness using three methods: stochastic search variable selection, participatory data science, and literature review-before being modeled using linear regression. Most participants (67.5%) reported having little to no awareness about PEP before initiating our study. Simple linear regression models suggested that higher PrEP knowledge (B = 0.17, SE = 0.02, p < 0.001), HIV knowledge (B = 0.15, SE = 0.04, p < 0.001), PrEP self-efficacy (B = 0.37, SE = 0.13, p < 0.05), and high perceived community norms for HIV testing (B = 0.29, SE = 0.14, p < 0.05) were each associated with LSMM's greater PEP awareness, while identity affirmation was associated with less PEP awareness (B = -0.13, SE = 0.05, p < 0.01). Results suggest the utility of our three-pronged variable selection approach and address gaps in PEP awareness and use among LSMM living in a US HIV epicenter to support Ending the HIV Epidemic goals.

Trends and Characteristics of #HIVPrevention Tweets Posted Between 2014 and 2019: Retrospective Infodemiology Study

BACKGROUND

Twitter is becoming an increasingly important avenue for people to seek information about HIV prevention. Tweets about HIV prevention may reflect or influence current norms about the acceptability of different HIV prevention methods. Therefore, it may be useful to empirically investigate trends in the level of attention paid to different HIV prevention topics on Twitter over time.

OBJECTIVE

The primary objective of this study was to investigate temporal trends in the frequency of tweets about different HIV prevention topics on Twitter between 2014 and 2019.

METHODS

We used the Twitter application programming interface to obtain English-language tweets employing #HIVPrevention between January 1, 2014, and December 31, 2019 (n=69,197, globally). Using iterative qualitative content analysis on samples of tweets, we developed a keyword list to categorize the tweets into 10 prevention topics (eg, condom use, preexposure prophylaxis [PrEP]) and compared the frequency of tweets mentioning each topic over time. We assessed the overall change in the proportions of #HIVPrevention tweets mentioning each prevention topic in 2019 as compared with 2014 using chi-square and Fisher exact tests. We also conducted descriptive analyses to identify the accounts posting the most original tweets, the accounts retweeted most frequently, the most frequently used word pairings, and the spatial distribution of tweets in the United States compared with the number of state-level HIV cases.

RESULTS

PrEP (13,895 tweets; 20.08% of all included tweets) and HIV testing (7688, 11.11%) were the most frequently mentioned topics, whereas condom use (2941, 4.25%) and postexposure prophylaxis (PEP; 823, 1.19%) were mentioned relatively less frequently. The proportions of tweets mentioning PrEP (327/2251, 14.53%, in 2014, 5067/12,971, 39.1%, in 2019; P≤.001), HIV testing (208/2251, 9.24%, in 2014, 2193/12,971, 16.91% in 2019; P≤.001), and PEP (25/2251, 1.11%, in 2014, 342/12,971, 2.64%, in 2019; P≤.001) were higher in 2019 compared with 2014, whereas the proportions of tweets mentioning abstinence, condom use, circumcision, harm reduction, and gender inequity were lower in 2019 compared with 2014. The top retweeted accounts were mostly UN-affiliated entities; celebrities and HIV advocates were also represented. Geotagged #HIVPrevention tweets in the United States between 2014 and 2019 (n=514) were positively correlated with the number of state-level HIV cases in 2019 (r=0.81, P≤.01).

CONCLUSIONS

Twitter may be a useful source for identifying HIV prevention trends. During our evaluation period (2014-2019), the most frequently mentioned prevention topics were PrEP and HIV testing in tweets using #HIVPrevention. Strategic responses to these tweets that provide information about where to get tested or how to obtain PrEP may be potential approaches to reduce HIV incidence.

Acceptability of Pre-Exposure Prophylaxis and Non-Occupational Post-Exposure Prophylaxis among Men Who Have Sex with Men in Guilin, China

Pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP) are both effective strategies for preventing HIV. There is limited information about the acceptability of these prevention measures in undeveloped areas of China. We aimed to examine the acceptability of PrEP and nPEP and their determinants among men who have sex with men (MSM). 219 MSM were recruited in Guilin, China. In total, 28.6% (95% CI: 20.0–41.0) and 35.9% (95% CI: 27.3–49.5) of the participants had heard of PrEP and nPEP, respectively, while 57.0% (95% CI: 43.1–68.2) and 58.6 (95% CI:44.8–68.8) reported they would be willing to use PrEP and nPEP after the methods were explained. A higher acceptability of PrEP was seen among participants who were previously married (aOR = 3.30; 95% CI: 1.22–9.19), working as a laborer (aOR = 5.13; 95% CI: 1.64–17.59), migrant workers/farmers (aOR = 2.56; 95% CI: 1.15–5.79), government employees (aOR = 4.76; 95%CI: 1.80–13.02), had higher social support (aOR = 1.05; 95% CI: 1.03–1.08), and had been previously tested for HIV (aOR = 2.79; 95% CI: 1.36–5.94). A higher acceptability of nPEP was associated with those having higher social support (aOR = 1.06; 95% CI: 1.04–1.09), not knowing their sexual partner’s HIV status (aOR = 2.72; 95% CI: 1.23–6.12), and having a prior HIV test (aOR = 5.53; 95% CI: 2.58–12.51). PrEP and nPEP are acceptable, especially among MSM with higher social support and had received a previous HIV test. Effective education and different dissemination strategies to promote the acceptance of PrEP and nPEP among MSM are needed.

Awareness and Use of Post-exposure Prophylaxis for HIV Prevention Among Men Who Have Sex With Men: A Systematic Review and Meta-Analysis

Background: The use of post-exposure prophylaxis (PEP) is effective in reducing HIV risk, but it is underused by men who have sex with men (MSM) due to certain psychological and sociostructural factors. This article assessed the awareness and use of PEP among MSM in an effort to increase the visibility and uptake of PEP among at-risk populations.

Methods: We conducted a systematic literature search of the PubMed, Web of Science, PsycINFO, and Google Scholar electronic databases. Studies were screened for inclusion, and relevant data were abstracted, assessed for bias, and synthesized. Pooled effect estimates were calculated using random effects meta-analysis, meta-regression and subgroup analysis, and a qualitative review and risk of bias assessment were performed (PROSPERO, CRD42019123815).

Results: Twenty eligible studies involving 12,579 MSM were included in the meta-analysis. The pooled estimate of the proportions of MSM who were aware of PEP was modest at 59.9% (95% CI: 50.5~68.7) and that of MSM who previously used PEP was very low at 4.9% (95% CI: 2.4~9.8). PEP awareness showed no clear change over time, while PEP use significantly changed over time. Multiple factors affected awareness, including educational attainment, race/ethnicity, levels of HIV stigma, access to condoms, and so on. Many factors could potentially impede or facilitate the use of PEP, such as income, lack of PEP information, and partnership.

Conclusion: We observed that PEP is an underused HIV prevention strategy among MSM and that once MSM become aware of PEP, the majority are willing to use it if they are supported appropriately in terms of a range of individual, social, and structural barriers.

Systematic Review Registration: http://www.cdr.york.ac.uk/prospero, PROSPERO [CRD42019123815].

Post-Exposure Prophylaxis and Methamphetamine Use among Young Sexual Minority Men: The P18 Cohort Study

Methamphetamine use is associated with increased risk of HIV infection among young sexual minority men (SMM). Post-exposure prophylaxis (PEP) is an effective strategy for individuals who are exposed to HIV, but there is limited research about PEP use among young SMM and its relationship with methamphetamine use. This study analyzes the association between ever PEP use and recent methamphetamine use among young SMM in New York City, using cross-sectional data from the P18 Cohort Study (n = 429). Multivariable logistic regression models were used to assess the association between methamphetamine use and ever PEP use. Compared with those who had not used methamphetamine in the last 6 months, young SMM who did use methamphetamine were significantly more likely to have ever used PEP (AOR = 6.07, 95% CI: 2.10–16.86). Young SMM who had ever used PrEP had 16 times higher odds of ever using PEP (AOR = 16, 95% CI: 7.41–35.95). Those who completed bachelor’s degrees were 61% less likely to have ever used PEP (AOR = 0.39, 95% CI: 0.17–0.88). These data suggest that methamphetamine use could increase the risk of HIV infection, highlighting the critical need to target interventions for young SMM who use methamphetamine and are more likely to engage in unprotected intercourse.

The characteristics of men who have sex with men (MSM) using post-exposure prophylaxis for sexual exposure (PEPSE) in the pre-exposure prophylaxis (PrEP) era

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) is now available in the UK. However, some men who have sex with men (MSM) continue to use HIV post-exposure prophylaxis following sexual exposure (PEPSE) and are not using PrEP. It is important to characterize MSM having condomless anal sex who are not using PrEP.

METHODS

In a cross-sectional analysis, we compared the characteristics of MSM who used PEPSE in 2021 with MSM using PEPSE in 2017.

RESULTS

Overall, 126 MSM used PEPSE in January to June 2017 and 28 MSM used PEPSE in January to June 2021, a 78% decline in PEPSE use. Those MSM using PEPSE in 2021 were significantly younger (27 vs. 35 years, p < 0.01), more likely to identify as black or from another minority ethnic group [29% (8/28) vs. 8% (10/126); p < 0.01], more likely to attend as a result of a group sex encounter [35% (10/28) vs. 16% (10/126); p = 0.03], more likely to attend following sex involving recreational drug use [32% (9/28) vs. 13% (16/126); p = 0.02], and more likely to initiate PEPSE in the emergency department [35% (10/28) vs. 19% (24/126); p = 0.04] compared with MSM attending in 2017. Those MSM using PEPSE in 2021 were significantly less likely to attend follow-up appointments compared with the 2017 cohort [71% (20/28) vs. 87% (110/126); p < 0.05]. Ninety-five per cent of MSM using PEPSE in 2021 were initiated on PrEP at follow-up.

CONCLUSIONS

Despite PrEP being readily available, some MSM continue using PEPSE and these MSM are significantly more likely to be younger, from black or minority ethnic groups, to engage in group sex involving recreational drugs and to attend the emergency department for PEPSE compared with MSM attending in 2017. Increasing the accessibility of PrEP for this group of MSM is important in order to optimize HIV prevention strategies.

Awareness and use of nonoccupational HIV post-exposure prophylaxis and factors associated with awareness among MSM in Beijing, China

Background

Human immunodeficiency virus (HIV) sexual transmission among men who have sex with men (MSM) has increased markedly in Beijing, China, during the past decade. Nonoccupational HIV post-exposure prophylaxis (nPEP) is a highly efficacious biomedical prevention strategy that significantly reduces HIV-transmission risk. This study examined nPEP awareness among MSM and the factors influencing it.

Methods

Consecutive, cross-sectional MSM surveys were conducted from April to August of 2018 and 2019. Demographic data as well as that on behavior and awareness regarding nPEP was collected. Factors influencing nPEP awareness were assessed using univariate and multivariable logistic regression.

Results

There were 1,202 eligible responders recruited. Of the responders, 42.5% had nPEP awareness, and 59.9% expressed interest in receiving nPEP in the future, if required. Greater odds of nPEP awareness were associated with younger age, higher education level (adjusted odds ratio [aOR]: 4.011, 95% confidence interval [CI]: 2.834–5.678, P<0.001), higher income, use of the Internet to meet sexual partners (aOR: 2.016, 95% CI: 1.481–2.744, P<0.001), greater HIV-related knowledge (aOR: 3.817, 95% CI: 1.845–7.899, p<0.001), HIV testing (aOR: 2.584, 95% CI: 1.874–3.563, p<0.001), and sexually transmitted infections (aOR: 1.736, 95% CI: 1.174–2.569, P = 0.006). Lower odds of nPEP awareness were associated with greater stigma score (aOR: 0.804, 95% CI: 0.713–0.906, P<0.001).

Conclusions

The findings indicate suboptimal awareness and low utilization of nPEP in Beijing and highlight nPEP inequities among MSM with stigma. Strengthening the training of health service providers and peer educators in reducing stigma and disseminating nPEP knowledge is imperative.

Awareness, Utilization, and Preferences for Traditional and Contemporary HIV Prevention Strategies Among Facebook and Instagram-Using MSM in the United States

HIV prevention research among men who have sex with men (MSM) has traditionally focused on individual risk reduction strategies. Our study evaluated awareness, utilization, and preferences for 10 complementary HIV prevention strategies among 1,286 MSM recruited via Facebook and Instagram from June-August 2018. Ages ranged from 18-85 years, and the majority were non-Hispanic white (n = 1,019, 79.24%), college-educated (n = 819, 63.69%), gay-identifying (n = 1,074, 83.51%), and partnered (n = 808, 62.83%). Post-exposure prophylaxis was the least familiar option, and engaging in sexual activities other than anal sex was the most utilized option. Progressively older and bisexual-identifying MSM were less likely, but those with higher educational levels and easy access to local HIV resources were more likely to be aware of and to be utilizing a greater number of strategies. Additionally, Hispanic MSM were less likely to be aware of, and those in a “closed” relationship were less likely to be utilizing a greater number of strategies. In a subset of 775 multiple strategy users, pre-exposure prophylaxis, regularly testing for HIV, and limiting the number of sex partners emerged as the most preferred options. Combination intervention packages for MSM should be tailored to personal circumstances, including sexual orientation, relationship characteristics and access to local HIV resources.

Knowledge and Use of PEP and PrEP Among Key Populations Tested in Community Centers in Portugal

Background: Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) have been increasingly available in Europe. Due to the high burden of HIV in key populations, these could benefit from their use. In 2016, in Portugal, an open, non-interval, prospective cohort study was established in a network of 26 community-based voluntary HIV/STI counseling and testing centers. Data collected included questions on PEP and PrEP knowledge and use. We aimed to estimate the proportion of PEP and PrEP knowledge and its use among key populations, visiting the centers between 2016 and 2019. Method and results: Individuals who self-identify as being among at least one key population for HIV, men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), migrants, and male-to-female transgender individuals (MTF), responded to questions on PEP and PrEP knowledge and use while waiting for their test results between 2016 and 2019 (n = 12,893 for PEP; n = 10,973 for PrEP). Reported knowledge was low in all key populations for both tools: 15.7% of respondents reported knowing about PEP and 10.9% about PrEP over the course of 4 years. PEP was used by 1.8% and PrEP by 0.4% of the respondents, MSM being 88.9% of PrEP users, and 52.8% of PEP users. Multivariate logistic regression showed multiple factors associated with knowing the tools, including age, education, country of birth, gender, year of test, having a reactive HIV test in the same visit, reporting an STI or condomless sex in the last 12 months, and identifying with being MSM or SW. Conclusions: Knowledge and use of PEP and PrEP remain low among key populations in Portugal. The need remains to increase knowledge and use among those at risk for HIV infection.

Predictors of Awareness, Accessibility and Acceptability of Pre-exposure Prophylaxis (PrEP) Among English- and Spanish-Speaking Latino Men Who have Sex with Men in Los Angeles, California

Uptake of pre-exposure prophylaxis (PrEP) among Latino men who have sex with men (LMSM) remains low. We examined awareness, accessibility, acceptability and use of PrEP among LMSM. LMSM were recruited using social/sexual networking apps. Multiple Logistic regressions identified significant predictors of PrEP awareness, accessibility and acceptability. Among 276 participants, only 6% reported current PrEP use. Among non-PrEP users, 85% reported PrEP awareness, 71% indicated high likelihood of future PrEP use, but only 35% reported knowledge about accessing PrEP. In multiple logistic regressions, a lower likelihood of PrEP awareness was associated with lower level education, whereas a higher likelihood was associated with reporting 6-10 or over 10 sexual partners. A lower likelihood of PrEP accessibility was associated with lower level education and undocumented status. A lower likelihood of PrEP acceptability was associated with an income of $15,001-30,000, whereas a higher likelihood was associated with lower level education and reporting 6-10 or over 10 sexual partners. PrEP promotion targeting Latino MSM should be expanded for those with lower levels of education and those who are undocumented.

What do patients consulting in a free sexual health center know about HIV transmission and post-exposure prophylaxis?

BACKGROUND

Screening, condom use and post-exposure prophylaxis (PEP) are among existing HIV prevention strategies. However, efficient use of these strategies requires that patients have an adequate knowledge of HIV transmission routes and awareness of risk behaviors. This study aimed to assess knowledge about HIV transmission among patients who attended a free HIV and sexually transmitted infection (STI) screening center in Paris, France, and to explore the patient profiles associated with HIV-related knowledge.

METHODS

This observational cross-sectional study included 2002 patients who attended for STI testing from August 2017 through August 2018 and completed a self-administered electronic questionnaire. Based on incorrect answers regarding HIV transmission, two outcomes were assessed: lack of knowledge and false beliefs. Factors associated with these two outcomes were explored using univariate and multivariate logistic regressions.

RESULTS

Only 3.6% of patients did not know about HIV transmission through unprotected sexual intercourse and/or by sharing needles. More than one third of patients (36.4%) had at least one false belief, believing that HIV could be transmitted by sharing a drink (9.7%), kissing (17.6%) or using public toilets (27.5%). A low educational level and no previous HIV testing were associated in multivariate analyses with both lack of knowledge and false beliefs. Age and sexual orientation were also associated with false beliefs. Furthermore, 55.6% of patients did not know that post-exposure prophylaxis consists of taking emergency treatment as soon as possible after risky intercourse.

CONCLUSIONS

Although the main HIV transmission routes are well known, false beliefs persist and knowledge regarding PEP needs to be improved. Prevention campaigns must focus on these themes which appear as a complementary strategy to pre-exposure prophylaxis to reduce HIV infection.

mHealth Strategies Related to HIV Postexposure Prophylaxis Knowledge and Access: Systematic Literature Review, Technology Prospecting of Patent Databases, and Systematic Search on App Stores

Background

Globally, the number of HIV cases continue to increase, despite the development of multiple prevention strategies. New cases of HIV have been reported disproportionately more in men who have sex with men and other vulnerable populations. Issues such as internalized and structural homophobia prevent these men from accessing prevention strategies such as postexposure prophylaxis (PEP). Mobile health (mHealth) interventions are known to be one of the newest and preferred options to enhance PEP knowledge and access.

Objective

The aim of this study was to identify and analyze the mobile apps addressing PEP for HIV infections.

Methods

We conducted a descriptive exploratory study in 3 sequential phases: systematic literature review, patent analysis, and systematic search of app stores. For the systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines adapted for an integrative review in the databases of PubMed, Web of Knowledge, Scopus, Cochrane, Embase, Science Direct, Eric, Treasure, and CINAHL. The patent analysis was performed by exploring the databases of the Brazilian National Institute of Industrial Property, the United States Patent and Trademark Office, and the European Patent Office. For the systematic search, we analyzed mHealth apps related to HIV in 2 major app libraries, that is, Google Play Store and App Store. The apps were evaluated by name, characteristics, functions, and availability in iPhone operating system/Android phones.

Results

We analyzed 22 studies, of which 2 were selected for the final stage. Both studies present the use of apps as mHealth strategies aimed at improving the sexual health of men who have sex with men, and they were classified as decision support systems. The search in the patent databases showed only 1 result, which was not related to the topic since it was a drug intervention. In the app libraries, 25 apps were found and analyzed, with 15 (60%) apps available for Android systems but only 3 (12%) addressing PEP. In general, the apps inform about HIV and HIV prevention and treatment, with the focus users being health care providers, people with HIV, or the general population, but they have only limited features available, that is, mainly text, images, and videos. The 3 apps exclusively focusing on PEP were created by researchers from Brazilian universities.

Conclusions

Our review found no connection between the scientific studies, registered patents, and the available apps related to PEP; this finding indicates that these available apps do not have a theoretical or a methodological background in their creation. Thus, since the scientific knowledge on HIV is not translated into technological products, preventing the emergence of new infections, especially in the more vulnerable groups, is difficult. In the future, researchers and the community must work in synergy to create more mHealth tools aimed at PEP.

Medical Gender Affirmation and HIV and Sexually Transmitted Disease Prevention in Transgender Youth: Results from the Survey of Today's Adolescent Relationships and Transitions, 2018

Purpose: We assessed the association of receipt of medical gender affirmation services (e.g., hormones, surgery) with HIV and other sexually transmitted disease (STD) prevention and knowledge indicators among transgender youth. Methods: A United States online sample of sexually experienced transgender youth ages 13-24 years (N = 1029) in 2018 completed a cross-sectional survey, including questions about sociodemographics, medical gender affirmation, and HIV and STD prevention outcomes (HIV testing, STD testing, pre-exposure prophylaxis [PrEP] awareness, and nonoccupational postexposure prophylaxis [nPEP] awareness). Logistic regression models were fit to assess the association of medical gender affirmation with HIV and STD prevention outcomes. Interaction terms and stratified models assessed differences in the association between medical gender affirmation and outcomes by gender identity. Results: Participants' mean age was 19.1 (standard deviation = 2.7), 45% were transgender female, 29% transgender male, 26% nonbinary, 53% were youth of color, and 19% accessed medical gender affirmation services. Medical gender affirmation was associated with increased odds of STD testing (adjusted odds ratio [aOR] = 1.90; 95% confidence interval [CI] = 1.33-2.73) with no significant interactions by gender identity. Associations between medical gender affirmation and awareness of PrEP and nPEP varied by gender identity. Among transgender male youth, medical gender affirmation was associated with awareness of PrEP (aOR = 2.65; 95% CI = 1.50-4.71) and nPEP (aOR = 2.03; 95% CI = 1.12-3.71). Among nonbinary youth, medical gender affirmation was associated with awareness of PrEP (aOR = 3.47; 95% CI = 1.26-11.27). Conclusion: Medical gender affirmation was associated with uptake and awareness of sexual health services. Bolstering medical gender affirmation for transgender youth may also bolster preventive health services broadly.

"It's Like Plan B but for HIV!" Design and Evaluation of a Media Campaign to Drive Demand for PEP

Post-exposure Prophylaxis (PEP) is an effective yet underutilized HIV prevention tool. PEPTALK developed and evaluated a media campaign to drive demand for PEP among men who have sex with men (MSM) and transgender women (TW) living in high HIV prevalence areas in New York City. Formative qualitative research (38 in-depth interviews and five focus groups [N = 48]) with Black or African-American MSM or TW who reported condomless sex with a HIV-positive/unknown status man was conducted to inform campaign design. We assessed the impact of the campaign, 15 bus shelter ads and low or no-cost social media, by assessing change in the proportions of new PEP patient visits, to the clinical site where the campaign directed consumers, using one-sided z-test for proportions, before and after the media campaign. The proportion of new PEP patients increased significantly after the media campaign in the periods examined, suggesting that such campaigns may increase PEP demand.

HIV Nonoccupational Postexposure Prophylaxis Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis of Global Data

HIV nonoccupational postexposure prophylaxis (nPEP) has been prescribed to men who have sex with men (MSM) for decades, but the global situation of nPEP implementation among this population remains unclear. To understand nPEP awareness, uptake, and factors associated with uptake among MSM, we searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science for studies reporting nPEP implementation among MSM published before May 19, 2019. We estimated pooled rates and their 95% confidence intervals (CIs) of awareness, uptake using a random-effects model. We identified 74 studies: 3 studies (4.1%) from upper-middle-income regions and 71 (95.9%) from high-income regions. The pooled rate of nPEP awareness and uptake was 51.6% (95% CI 40.6-62.5%) and 6.0% (5.0-7.1%), respectively. Pooled uptake rate was higher in upper-middle-income regions [8.9% (7.8-10.0%)] than in high-income regions [5.8% (4.8-6.9%)]. Unprotected anal sex was the most common exposure (range: 55.0-98.6%, median: 62.9%). Pooled completion of nPEP was 86.9% (79.5-92.8%). Of 19,546 MSM prescribed nPEP, 500 HIV seroconversions (2.6%) were observed. Having risky sexual behaviors and history of sexually transmitted infections were associated with higher nPEP uptake, whereas insufficient knowledge, underestimated risk of exposure to HIV, lack of accessibility, and social stigma might hinder nPEP uptake. Awareness and uptake of nPEP among MSM worldwide are low. Further efforts are needed to combat barriers to access nPEP, including improving accessibility and reducing stigma. Seroconversions post-nPEP uptake suggest that joint prevention precautions aside from nPEP are needed for high-risk MSM. More evidence from low-income and middle-income regions is needed.

Post-exposure prophylaxis: an underutilized biomedical HIV prevention method among gay, bisexual and other men who have sex with men in China

Despite abundant evidence on its safety, tolerability and cost-effectiveness, post-exposure prophylaxis (PEP) has not been officially approved for non-occupational use in China. This study aims to assess awareness of, willingness to use, and actual experience with PEP in gay, bisexual and other men who have sex with men (GBM) in China and to explore potential associations between demographic, behavioral, and psychosocial factors and PEP-related outcomes. We recruited a convenience sample through community venue-based strategies, peer referrals, and online advertisement in four cities of China in 2018. We used bivariable and multivariable logistic regression to test associations between potential predictors and PEP outcomes. Over 60% of men reported having heard of PEP prior to the survey, 70% would be willing to use it if exposed to HIV, and 6% reported having used PEP. Awareness of PEP was associated with higher education, more frequent HIV testing, knowing someone who seroconverted in the past two years, having sex with only men in the past six months, and lower perceived risk of HIV infection. PEP willingness was associated with more frequent HIV testing, being worried about becoming HIV infected, prior awareness and favorable attitudes towards PEP among friends. Findings suggest PEP is an underutilized diomedical HIV prevention intervention among GBM in China. Clinical guidance on non-occupational PEP use, as well as communication campaigns targeting social networks of GBM are needed to address barriers to PEP awareness and uptake.

Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research

RATIONALE

A growing body of transgender (trans) health research has explored the relationship between stigma and health; yet, studies have conceptualized and operationalized anti-trans stigma in multiple ways.

OBJECTIVE

This scoping review aims to critically analyze quantitative measures of anti-trans stigma in the U.S. using a socioecological framework.

METHOD

We organized and appraised measures from 126 included articles according to socioecological level: structural, interpersonal, or individual.

RESULTS

Of the identified articles, 36 measured anti-trans stigma at the structural level (i.e., institutional structures and policies), 102 measured anti-trans at the interpersonal level (i.e., community interactions), and 44 measured anti-trans stigma at the individual level (i.e., internalized or anticipated stigma). Definitions of anti-trans stigma varied substantially across articles. Most measures were adapted from measures developed for other populations (i.e., sexual minorities) and were not previously validated for trans samples.

CONCLUSIONS

Studies analyzing anti-trans stigma should concretely define anti-trans stigma. There is a need to develop measures of anti-trans stigma at all socioecological levels informed by the lived experiences of trans people.

PrEP Stigma, HIV Stigma, and Intention to Use PrEP among Women in New York City and Philadelphia

Background

Stigma is an important contributor to the continued HIV epidemic in the United States (US). In 2016, women made up nearly one in five of all new infections. Pre-exposure HIV Prophylaxis or PrEP is a medication that can be taken to prevent HIV acquisition; however, PrEP is significantly underutilized by women at risk for infection. How PrEP stigma relates to PrEP initiation among women is not well understood.

Methods

Surveys were completed by 160 PrEP-eligible women aged 18-55 in Philadelphia, PA and New York City, NY. Associations between PrEP stigma, HIV stigma, and PrEP initiation intention were modeled using multinomial logistic regression, controlling for sociodemographic and theoretically-relevant variables.

Results

Participants ranged in age from 18 to 55 years (M = 40.2; SD = 11.78). Most (79%) identified as Black or African-American and/or Latina and 36% had completed high-school or less. Higher PrEP stigma was significantly associated with lower PrEP initiation intention, while controlling for other theoretically-relevant and sociodemographic variables. HIV stigma was not related to PrEP initiation intention.

Conclusions

HIV prevention interventions seeking to increase PrEP initiation among PrEP-eligible, urban women need to address the role that PrEP stigma plays in PrEP uptake.